SBI Life Advisor

DGH

Enter Your Proposal Number *

Personal Details

Name of the Life Assured

Date of Birth

Age

Gender

Occupation

Residence Status

Country of Residence

Contact Details

Country Code

Mobile Number

Email Id

Height (in Cms)

Weight (in Kgs)

1) Are you at present in GOOD health? If No, Please provide details below

Yes

2) During the last one year, has there been any increase/decrease in your weight over 5 Kilograms.If yes, please provide full details in the space below

Yes

3) Since the Date of Proposal of this policy

a) Have you suffered from any illness / disease requiring treatment for 3 or more days? If yes, give full details

Yes

b) Do you plan or have been advised to undergo any surgery or hospitalization or visit to doctor or practitioner for any physical, mental or emotional condition, injury, or sickness in near future. If yes, please provide details in the space below

Yes

c) In the last 5 year, apart from minor ailments like cough/cold etc, have you received any treatment under doctor’s consultation and /or undergone any major surgery and/or been hospitalized and/or undergone major investigations like CT/MRI scan, Angiogram, Endoscopy, Biopsy etc? If yes, please provide full details in the space below

Yes

4) Do you suffer from or have ever suffered from: Raised Blood sugar, Diabetes mellitus, high blood pressure, Disease of heart, lung, kidney, Liver, thyroid, brain/nervous system, bone/joint/spine, Genitourinary tract, any part of the body or blood disorder, digestive disorder, Gynaecological disorder, Psychiatric disorder, HIV/AIDS and/or cancer/tumour of any part of the body. If yes, please provide full details in the space below

Yes

5) Has any of your proposals for life insurance, critical illness or health insurance, ever been denied, declined, rejected, postponed or accepted with extra premium due to health or lifestyle reason If yes, please provide full details in the space below

Yes

6) Are you exposed to any special hazard associated with your occupation (e.g. chemical factory, mines, explosives, corrosives, combative duties, oil exploration, high sea voyage etc.) which may render you susceptible to injuries or illnesses? If Yes, please provide details in the occupation questionnaire and submit along with this declaration.

Yes

7) Are you a “Politically Exposed Person” (PEP) or a close relative of PEP?
PEPs are individuals who are or have been entrusted with prominent public functions, i.e. heads / ministers of central / state govt., senior politicians, senior govt, judicial or military officials, senior executives of govt. companies, important political party officials, immediate family member of above persons (would include spouse, parents, siblings, children, spouses parents or siblings and close associates of PEPs
If yes, give full details. If No, in case of change in your PEP status in future, you shall inform SBI Life of such change

Yes

8) History of criminal proceedings, FIR or conviction.
a) Has any FIR or Criminal Complaint ever been registered or lodged against you? If yes, give full details

Yes

b) Have there been any Criminal proceedings initiated against you either in the past or in the present? If yes, give full details

Yes

c) Do you have any history of conviction under any criminal proceedings in India or abroad? If yes, give full details

Yes

9) Do you take part in or have you any intention of taking part in any hazardous sports, hobbies, activities or pursuits, for example mountaineering, Diving, racing or aviation other than as a fare paying passenger, that could be dangerous in any way? If yes, give full details

Yes

10) a) Do you consume any of the following?

Tobacco (cigs, cigar, gutkha, etc)

Yes

Alcohol

Yes

Any Narcotics

Yes

b) If you have quit any of the above in the last 1 year, kindly provide details

COVID Questionnaire (UWM029)

1. Have you visited any foreign country after 1.1.2020:

Yes

1.1 Name of Country visited

From:

To:

1.3 Date of return to India:

1.4 If you have been screened at the airport please provide copy of the reports

Yes

2 Have you been tested for COVID-19. If yes, all the reports of same till date

Yes

3 Please confirm if either of the following is applicable to you

3.1 Kept in home quarantine anytime (till date) since 1.1.2020

Yes

3.2 Kept under observation anytime (till date) since 1.1.2020

Yes

3.3 Kept in home isolation/self isolation anytime (till date)since 1.1.2020

Yes

4 Do you plan to travel to any foreign countries in next 6 months

Yes

4.1 Name of Country visited

4.2 From:

4.2 To:

4.3 Date of return to India:

5 Have you or your immediate family members/co-habitants suffered from any signs and symptoms of flu(cough, cold, fever more than 05 days) since 1.1.2020(whether any medical consultation taken or not)?

Yes

6 Have you or your immediate family members undergone or been advised to undergo any test/investigations or hospitalized for observation or treatment in past 2 months for respiratory symptoms?

Yes

7 Have you or any of your immediate familymembers/cohabitants come in contact with suspected or confirmed cases of coronavirus

Yes

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Identity				Successful
Address				Successful
Others				Successful

FOR OFFICE USE

KYC Details

Proposer Photo			Successful
LM/CIF/BDM/UM Photo			Successful

DECLARATION WHEN THE DGH IS FILLED BY A PERSON OTHER THAN THE PROPOSER /POLICYHOLDER / MEMBER INSURED IN VERNACULAR LANGUAGE/ PROPOSER /POLICYHOLDER / MEMBER INSURED IS ILLITERATE

I hereby declare that I have read out and explained the contents of this proposal form and all other documents incidental to availing the insurance policy from SBI Life Insurance Company Ltd. to the Proposer /policyholder/member insured and that he/she declared that he/she has understood the same completely.
I hereby declare that I have fully explained to the Proposer /policyholder/member insured the answers to the questions that form the basis of the contract of insurance and I also explained to the Proposer /policyholder/member insured that if there is any mis-statement or suppression of material information or if any untrue statements are contained therein or in case of fraud, the said contract shall be treated as per the provisions of Section 45 of the Insurance Act 1938 as amended from time to time.

Select Form Content Explanation Language

I hereby declare that I have discussed this case with the Advisor and confirm on the basis of my independent assessment and evaluation that the foregoing statements are correct.

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User Name

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